ROX (Respiratory rate-OXygenation) index to predict early response to high-flow nasal cannula therapy in infants with viral bronchiolitis.

INTRODUCTION: High-flow nasal cannula (HFNC) is commonly used as first step respiratory support in infants with moderate-to-severe acute viral bronchiolitis (AVB). This device, however, fails to effectively manage respiratory distress in about a third of patients, and data are limited on determinants of patient response. The respiratory rate-oxygenation (ROX) index is a relevant tool to predict the risk for HFNC failure in adult patients with lower respiratory tract infections. The primary objective of this study was to assess the relationship between ROX indexes collected before and 1 h after HFNC initiation, and HFNC failure occurring in the following 48 h in infants with AVB. METHOD: This is an ancillary study to the multicenter randomized controlled trial TRAMONTANE 2, that included 286 infants of less than 6 months with moderate-to-severe AVB. Collection of physiological variables at baseline (H0), and 1 h after HFNC (H1), included heart rate (HR), respiratory rate (RR), fraction of inspired oxygen (FiO2), respiratory distress score (modified Wood's Clinical Asthma Score [mWCAS]), and pain and discomfort scale (EDIN). ROX and ROX-HR were calculated as SpO 2 FiO 2 RR $\frac{\left(\frac{{\mathrm{SpO}}_{2}}{{\mathrm{FiO}}_{2}}\right)}{\mathrm{RR}}$ and 100 × ROX HR $100\times \frac{\mathrm{ROX}}{\mathrm{HR}}$ , respectively. Predefined HFNC failure criteria included increase in respiratory distress score or RR, increase in discomfort, and severe apnea episodes. The accuracies of ROX, ROX-HR indexes and clinical variable to predict HFNC failure were assessed using receiver operating curve analysis. We analyzed predictive factors of HFNC failure using multivariate logistic regressions. RESULT: HFNC failure occurred in 111 of 286 (39%) infants, and for 56 (50% of the failure) of them within the first 6 h. The area under the curve of ROX indexes at H0 and H1 were, respectively, 0.56 (95% confidence interval [CI] 0.48-0.63, p = 0.14), 0.56 (95% CI 0.49-0.64, p = 0.09). ROX-HR performances were better but remained poorly discriminant. HFNC failure was associated with higher mWCAS score at H1 (p < 0.01) and lower decrease in EDIN scale during the first hour of HFNC delivery (p = 0.02). In the multivariate analyses, age and mWCAS score were were found to be independent factors associated with HFNC failure at H0. At H1, weight and mWCAS were associated factors. CONCLUSION: In this study, neither ROX index, nor physiological variables usually collected in infants with AVB had early discriminatory capacity to predict HFNC failure.

Measurement of the interbronchial angle in acute viral bronchiolitis.

BACKGROUND: Acute viral bronchiolitis (AVB) is the most common lower airway infection in children under 2 years. Attempts to determine disease severity based on clinical and radiological manifestations are a major challenge. Measurements of the anatomy of the trachea and main bronchi are not only limited to pure anthropometry, but are also useful for better care of critically ill patients. The purpose of the study is to verify the association between measurements of the interbronchial angle (ITB) and the severity of respiratory disease. METHODS: A cross-sectional study, which included all patients admitted to the Santo Antônio Children's Hospital, over a period of 1 year, with diagnosis of AVB by respiratory syncytial virus (RSV) was designed. ITB angle was measured and clinical characteristics were analyzed. Quantitative variables were compared and correlation analysis was performed using Pearson's correlation coefficient. A receiving operator characteristic (ROC) curve was performed. P-value <0.05 was statistically significant. RESULTS: A total of 425 patients with AVB due to RSV were included. Most of these patients were male and the median age was 130 days, 91.11% of them required oxygen therapy through a nasal catheter, 3.3% used noninvasive ventilation and 4% used mechanical ventilation. Those who required MV or NIV and intensive care unit support were considered severe. The mean ITB was lower for these patients than for those of lesser severity (p < 0.05). CONCLUSION: The present study demonstrates that there is an association between ITB and AVB severity. The smaller the ITB, the greater the disease severity.

Respiratory effort during noninvasive positive pressure ventilation and continuous positive airway pressure in severe acute viral bronchiolitis.

OBJECTIVES: To assess if noninvasive positive pressure ventilation (NIPPV) is associated with a greater reduction in respiratory effort as compared to continuous positive airway pressure (CPAP) during severe acute bronchiolitis, with both supports set either clinically or physiologically. METHODS: Twenty infants (median [IQR] age 1.2 [0.9; 3.2] months) treated <24 h with noninvasive respiratory support (CPAP Clin, set at 7 cmH2 O, or NIPPV Clin) for bronchiolitis were included in a prospective single-center crossover study. Esogastric pressures were measured first with the baseline support, then with the other support. For each support, recordings were performed with the clinical setting and a physiological setting (CPAP Phys and NIPPV Phys), aiming at normalising respiratory effort. Patients were then treated with the optimal support. The primary outcome was the greatest reduction in esophageal pressure-time product (PTPES /min). Other outcomes included improvement of the other components of the respiratory effort. RESULTS: NIPPV Clin and Phys were associated with a lower PTPES /min (164 [105; 202] and 106 [78; 161] cmH2 O s/min, respectively) than CPAP Clin (178 [145; 236] cmH2 O s/min; p = 0.01 and 2 × 10-4 , respectively). NIPPV Clin and Phys were also associated with a significant reduction of all other markers of respiratory effort as compared to CPAP Clin. PTPES /min with NIPPV (Clin or Phys) was not different from PTPES /min with CPAP Phys. There was no significant difference between physiological and clinical settings. CONCLUSION: NIPPV is associated with a significant reduction in respiratory effort as compared to CPAP set at +7 cmH2 O in infants with severe acute bronchiolitis. CPAP Phys performs as well as NIPPV Clin.

Bronchiolitis therapies and misadventures.

Viral bronchiolitis, which is most commonly caused by an infection with the respiratory syncytial virus (RSV), can lead to respiratory difficulties in young children which may require hospitalization. Despite years of research and medical trials, the mainstay of bronchiolitis treatment remains supportive only. This review provides an overview of the history of different treatments for bronchiolitis, including those that failed, as well as new therapies that are under study. Future studies for the treatment of bronchiolitis should consider different age-groups, important subgroups (i.e., those with a prior history of wheezing, those with a family history of asthma and those with non-RSV viral etiologies) whose response to treatment may differ from that of the composite group.

Respiratory Syncytial Virus is the Most Common Causative Agent of Viral Bronchiolitis in Young Children: An Updated Review.

BACKGROUND: Viral bronchiolitis is a common condition and a leading cause of hospitalization in young children. OBJECTIVE: This article provides readers with an update on the evaluation, diagnosis, and treatment of viral bronchiolitis, primarily due to RSV. METHODS: A PubMed search was conducted in December 2021 in Clinical Queries using the key terms "acute bronchiolitis" OR "respiratory syncytial virus infection". The search included clinical trials, randomized controlled trials, case control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to children and English literature. The information retrieved from the above search was used in the compilation of this article. RESULTS: Respiratory syncytial virus (RSV) is the most common viral bronchiolitis in young children. Other viruses such as human rhinovirus and coronavirus could be etiological agents. Diagnosis is based on clinical manifestation. Viral testing is useful only for cohort and quarantine purposes. Cochrane evidence-based reviews have been performed on most treatment modalities for RSV and viral bronchiolitis. Treatment for viral bronchiolitis is mainly symptomatic support. Beta-agonists are frequently used despite the lack of evidence that they reduce hospital admissions or length of stay. Nebulized racemic epinephrine, hypertonic saline and corticosteroids are generally not effective. Passive immunoprophylaxis with a monoclonal antibody against RSV, when given intramuscularly and monthly during winter, is effective in preventing severe RSV bronchiolitis in high-risk children who are born prematurely and in children under 2 years with chronic lung disease or hemodynamically significant congenital heart disease. Vaccines for RSV bronchiolitis are being developed. Children with viral bronchiolitis in early life are at increased risk of developing asthma later in childhood. CONCLUSION: Viral bronchiolitis is common. No current pharmacologic treatment or novel therapy has been proven to improve outcomes compared to supportive treatment. Viral bronchiolitis in early life predisposes asthma development later in childhood.

Comparison of two oxygen saturation targets to decide on hospital discharge of infants with viral bronchiolitis living at high altitudes: a cost-effectiveness analysis.

OBJECTIVES: The objective of the current study was to evaluate the cost-effectiveness of two pulse oximetry (SpO2) thresholds to decide on hospital discharge when all other discharge criteria are met, in infants with viral bronchiolitis living at high altitudes. METHODS: A decision analysis model was developed to estimate the cost-effectiveness of the use of an SpO2 threshold of 90% versus one of 85% for deciding whether infants hospitalized for viral bronchiolitis can be safely discharged to home, from a third-party payer's perspective. The main outcome was discharge to home at day 4 of the initial hospitalization. The time horizon was 28 days after discharge from hospital. We performed deterministic sensitivity analyses and probabilistic sensitivity analyses. RESULTS: Compared to the use of an SpO2 threshold of 90%, treating infants with viral bronchiolitis with the use of an SpO2 threshold of 85% resulted in lower total costs (US$119.39 vs. US$188.357 mean cost per patient) and a greater probability of discharge to home at day 4 of the initial hospitalization (0.8400 vs. 0.7600), therefore being a dominant strategy. Sensitivity analyses were in line with base case results. CONCLUSIONS: In Bogota, a high-altitude city, in infants admitted for viral bronchiolitis, the use of an SpO2 threshold of 85% to decide on hospital discharge when all other discharge criteria are met is dominant because it entails a greater probability of discharge to home at day 4 of the initial hospitalization and generates fewer costs than the use of an SpO2 threshold of 90%.

High-Frequency Percussive Ventilation in Viral Bronchiolitis.

BACKGROUND: High-frequency percussive ventilation (HFPV) is an alternative mode of mechanical ventilation that has been shown to improve gas exchange in subjects with severe respiratory failure. We hypothesized that HFPV use would improve ventilation and oxygenation in intubated children with acute bronchiolitis. METHODS: In this single-center prospective cohort study we included mechanically ventilated children in the pediatric ICU with bronchiolitis 1-24 months old who were transitioned to HFPV from conventional invasive mechanical ventilation from November 2018-April 2020. Patients with congenital heart disease, on extracorporeal membrane oxygenation (ECMO), and with HFPV duration < 12 h were excluded. Subject gas exchange metrics and ventilator parameters were compared before and after HFPV initiation. RESULTS: Forty-one of 192 (21%) patients intubated with bronchiolitis underwent HFPV, and 35 met inclusion criteria. Median age of cohort was 4 months, and 60% were previously healthy. All subjects with available oxygenation saturation index (OSI) measurements pre-HFPV met pediatric ARDS criteria (31/35, 89%). Mean CO2 decreased from 65.4 in the 24 h pre-HFPV to 51 (P < .001) in the 24 h post initiation. SpO2 /FIO2 was significantly improved at 24 h post-HFPV (153.3 to 209.7, P = .001), whereas the decrease in mean OSI at 24 h did not meet statistical significance (11.9 to 10.2, P = .15). The mean peak inspiratory pressure (PIP) decreased post-HFPV from 29.7 to 25.0 at 24 h (P < .001). No subjects developed an air leak or hemodynamic instability secondary to HFPV. Two subjects required ECMO, and of these, one subject died. CONCLUSIONS: HFPV was associated with significant improvement in ventilation and decreased exposure to high PIPs for mechanically ventilated children with bronchiolitis in our cohort and had a potential association with improved oxygenation. Our study shows that HFPV may be an effective alternative mode of ventilation in patients with bronchiolitis who have poor gas exchange on conventional invasive mechanical ventilation.

Emergency department-initiated home oxygen for viral bronchiolitis: A cost-effectiveness analysis.

OBJECTIVE: The use of emergency department (ED)-initiated outpatient oxygen therapy has been considered to be a possible alternative to hospitalization for otherwise healthy-appearing, well-hydrated infants with uncomplicated disease. However, a formal economic evaluation of this treatment strategy is lacking. The aim of the present study was to compare the cost-effectiveness of ED-initiated outpatient oxygen therapy versus conventional inpatient hospitalization in infants with uncomplicated hypoxic bronchiolitis living in Bogota, the high-altitude capital city of Colombia, a middle-income country (MIC). METHODS: A decision analysis model was developed to estimate the cost-effectiveness of ED-initiated outpatient oxygen therapy versus hospitalization. The main outcome of the model was avoidance of admission to a high-dependency unit. RESULTS: Compared to hospitalization, ED-initiated outpatient oxygen therapy was associated with lower total costs (US$306.7 vs. US$638.7 average cost per patient) and a higher probability of avoidance of admission to a high-dependency unit (0.9528 vs. 0.8960), thus leading to dominance. The results were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS: Our study suggests that in infants attending the ED with an uncomplicated hypoxic bronchiolitis episode in the city of Bogota, a high-altitude city, ED-initiated outpatient oxygen therapy is a dominant strategy compared to conventional inpatient hospitalization, because it involves a higher probability of avoidance of admission to a high-dependency unit, at lower total treatment costs.

Evaluation of reported medical services provided to pediatric viral bronchiolitis diagnoses during the COVID-19 pandemic.

BACKGROUND: Mitigation strategies were implemented during the coronavirus disease 2019 (COVID-19) pandemic that slowed the spread of this virus and other respiratory viruses. The objective of this study is to assess the impact of COVID-19 mitigation strategies on the medical services that children less than 1 year of age with acute bronchiolitis required (emergency department services, hospitalization, critical care services, and mechanical ventilation). METHODS: This was a retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects less than 1 year of age with a diagnosis of acute bronchiolitis. After the query, the study population was divided into two groups [pre-COVID-19 (March 1st, 2019 until February 29th, 2020) and COVID-19 (March 1st, 2020 until February 1th, 2021)]. We analyzed the following data: age, sex, race, diagnostic codes, common terminology procedures (CPT), and antimicrobials administered. RESULTS: A total of 5063 subjects (n,%) were included [4378 (86.5%) pre-COVID-19 and 685 (13.5%) during the COVID-19 pandemic]. More subjects were diagnosed with acute bronchiolitis in the pre-COVID time frame (4378, 1.8% of all hospitalizations) when compared to the COVID-19 pandemic time frame (685, 0.5%). When diagnosed with acute bronchiolitis, the frequency of emergency department services, critical care services, hospitalization, and mechanical ventilationwere similar between the two cohorts. CONCLUSIONS: During the COVID-19 pandemic, less infants were diagnosed with acute bronchiolitis but the frequency of emergency department services, hospitalization, and mechanical ventilation, reportedly required was similar. Longer-term studies are needed to evaluate the benefits of COVID-19 mitigation strategies on common viruses that require critical care.

Antimicrobial Stewardship in Bronchiolitis: A Retrospective Cohort Study of Three PICUs in Canada.

OBJECTIVES: To determine the association between the implementation of an antimicrobial stewardship program at a local PICU and to determine the association between the presence of an antimicrobial stewardship programs and antimicrobial use across three Canadian PICUs, among critically ill children with bronchiolitis. DESIGN: A multicenter retrospective cohort study. SETTING: Three Canadian PICUs over two winter seasons. INTERVENTIONS: An antimicrobial stewardship program was implemented at PICU 1 at the end of season 1. PATIENTS: Patients less than or equal to 2 years old admitted with bronchiolitis. MEASUREMENTS AND MAIN RESULTS: We used regression models with an interaction term between site (PICU 1 and PICU 2) and season (1 and 2) as the primary analysis to determine the association between implementation of an antimicrobial stewardship program at PICU 1 and 1) the proportion of antimicrobials discontinued 72 hours after hospital admission (logistic regression), 2) antimicrobial treatment duration (negative binomial regression), and 3) antimicrobial prescriptions within 48 hours of hospital admission (logistic regression). As a secondary analysis, we determined the association between having an antimicrobial stewardship program present and the aforementioned outcomes across the three PICUs. A total of 372 patients were included. During seasons 1 and 2, median age was 2.2 months (interquartile range, 1.2-6.2 mo) and 2.1 months (interquartile range, 1.3-6.8 mo), respectively. Among patients with viral bronchiolitis, implementation of an antimicrobial stewardship program at PICU 1 was associated with increased odds of discontinuing antimicrobials (odds ratio, 25.63; 95% CI, 2.86-326.29), but not with antimicrobial duration (odds ratio, 0.56; 95% CI, 0.31-1.02) or antimicrobial prescriptions (odds ratio, 0.33; 95% CI, 0.10-1.04). The presence of an antimicrobial stewardship program was similarly associated with antimicrobial discontinuation among patients with viral bronchiolitis (odds ratio, 20.79; 95% CI, 2.46-244.92), but not with antimicrobial duration (odds ratio, 0.57; 95% CI, 0.32-1.03) or antimicrobial prescriptions (odds ratio, 0.37; 95% CI, 0.12-1.11). CONCLUSIONS: Antimicrobial stewardship programs were associated with increased likelihood of discontinuing antimicrobial treatments in the PICU patients with viral bronchiolitis. However, larger studies are needed to further determine the role of an antimicrobial stewardship programs in reducing unnecessary antimicrobial use in this patient population.

Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline.

Importance: Acute viral bronchiolitis is a common and costly pediatric condition for which clinical practice guidelines discourage use of diagnostic tests and therapies. Objective: To evaluate trends over time for use of nonrecommended services for bronchiolitis since publication of the American Academy of Pediatrics clinical practice guideline on bronchiolitis (originally published in October 2006 and updated in November 2014). Design, Setting, and Participants: This cohort study was conducted using interrupted time-series regression analysis adjusting for the hospital providing service, patient demographic characteristics, and payer, with 2014 guideline update publication as the event point. Included patients were children younger than 2 years old discharged from the emergency department (ED) or hospital inpatient setting with a primary diagnosis of bronchiolitis at US Children's Hospitals contributing data to the Pediatric Health Information Systems database. Data were analyzed from June through December 2020. Main Outcomes and Measures: Rates of nonrecommended tests (ie, chest radiography, viral testing, and complete blood cell count) and treatments (ie, bronchodilators, corticosteroids, antibiotics) were measured. Results: Among 602 375 encounters involving children with a primary diagnosis of bronchiolitis, 404 203 encounters (67.1%) were ED discharges and 198 172 encounters (32.9%) were inpatient discharges; 468 226 encounters (77.7%) involved children younger than 12 months, and 356 796 encounters (59.2%) involved boys. In the period after initial guideline publication (ie, November 2006 to November 2014), a negative use trajectory was found in all measures except viral testing in the ED group. Using the 2014 guideline update as the event point, several measures showed decreased use between study time periods. The greatest decrease was in bronchodilator use, which changed by -13.5 percentage points in the ED group (95% CI, -15.2 percentage points to -11.8 percentage points) and -11.3 percentage points in the inpatient group (95% CI, -13.1 percentage points to -9.4 percentage points). In the period after the 2014 guideline update (ie, December 2014 to December 2019), bronchodilators also showed the greatest change in usage trajectory, steepening more than 2-fold in both groups. In the ED group, the negative trajectory steepened from -0.11% monthly (95% CI, -0.13% to -0.09%) in the first guideline period to a new mean monthly slope of -0.26% (95% CI, -0.30% to -0.23%). In the inpatient group, the mean monthly slope steepened from -0.08% (95% CI, -0.10 to -0.05%) to -0.26% (95% CI, 0.30% to -0.22%). Length of stay decreased from 2.0 days (95% CI, 1.9 days to 2.1 days) to 1.7 days (95% CI, 1.7 days to 1.8 days). Hospital admission rate decreased from 18.0% (95% CI, 13.8% to 22.2%) to 17.8% (95% CI, 13.6 to 22.1%). Conclusions and Relevance: This cohort study with interrupted time-series analysis found that use of most nonrecommended bronchiolitis services decreased continuously after 2006. The rate of decline in bronchodilator use increased more than 2-fold after the 2014 guideline update. These findings support potential associations of practice guidelines with improved bronchiolitis care.

Invasive Mechanical Ventilation for Acute Viral Bronchiolitis: Retrospective Multicenter Cohort Study.

OBJECTIVES: Bronchiolitis is a leading cause of PICU admission and a major contributor to resource utilization during the winter season. Management in mechanically ventilated patients with bronchiolitis is not standardized. We aimed to assess whether variations exist in management between the centers and then to assess if differences in PICU outcomes are found. DESIGN: Retrospective cohort study. SETTING: Three tertiary PICUs (Centers A, B, and C) in London, United Kingdom. PATIENTS: Patients under 1 year of age (n = 462) who received invasive mechanical ventilation for acute viral bronchiolitis from 2012-2016. INTERVENTIONS: None. DESIGN: Retrospective cohort study. MEASUREMENTS AND MAIN RESULTS: Data collected include all sedative agents administered, 48 hour cumulative fluid balance and location of endotracheal tube (oral or nasal). Primary outcome was duration of invasive mechanical ventilation. A generalized linear model was used to test for differences in duration of invasive mechanical ventilation between centers after adjustment for confounders: corrected gestational age, oxygen saturation index, bacterial coinfection, prematurity, respiratory syncytial virus status, risk of mortality score and comorbidity. Baseline characteristics were similar, other than a higher risk of mortality score at center A and higher admission oxygen saturation index at center C. Center A was associated with utilization of the most benzodiazepine and opiate sedation, the fewest nasal endotracheal tubes, and the highest mean cumulative fluid balance at 48 hours.Center A had an adjusted mean duration of invasive mechanical ventilation that was 44% longer than center C (95% CI, 25-66%; p < 0.001).The majority of confounders had an association with the duration of invasive mechanical ventilation; all were biologically plausible. Corrected gestational age was negatively associated with the duration of invasive mechanical ventilation for preterm infants less than 32 weeks, but not for term or 32-37 week infants (interaction effect). This meant that at a corrected age of 0 months, a less than 32-week infant had a mean duration that was 55% greater than a term infant: this effect had disappeared by 8 months old. CONCLUSIONS: Between-center variations exist in both practices and outcomes. The relationship between these two findings could be further tested through implementation science with "optimal care bundles."

Assessment of Peak Inspiratory Flow in Young Infants with Acute Viral Bronchiolitis: Physiological Basis for Initial Flow Setting in Patients Supported with High-Flow Nasal Cannula.

OBJECTIVE: To assess the inspiratory demand in young infants with acute viral bronchiolitis to provide a physiological basis for initial flow setting for patients supported with high flow nasal cannula. STUDY DESIGN: Prospective study in 44 infants up to 6 months old with acute viral bronchiolitis, admitted to a pediatric intensive care unit from November 2017 to March 2019. Airflow measurements were performed using spirometry. The primary endpoint was the inspiratory demand as measured by peak tidal inspiratory flow (PTIF). The secondary endpoints were the relationships determined between PTIF, patient weight, and disease severity. RESULTS: Median (Q25-Q75) age and weight of the patients were 37 (20-67) days and 4.3 (3.5-5.0) kg, respectively. Mean PTIF was 7.45 (95% CI 6.51-8.39, min-max: 2.40-16.00) L/minute. PTIF indexed to weight was 1.68 (95% CI 1.51-1.85, min-max: 0.67-3.00) L/kg/minute. PTIF was <2.5 L/kg/minute in 89% (95% CI 75-96) of infants. PTIF was correlated with weight (ρ= 0 .55, P < .001) but not with markers of disease severity, including modified Woods clinical asthma score, Silverman-Andersen score, respiratory rate, fraction of inspired oxygen, and PCO2. CONCLUSIONS: High flow nasal cannula therapy is used commonly to support infants with acute viral bronchiolitis. The efficiency of the device is optimal if the flow setting matches the patient's inspiratory demand. According to our results, a flow rate of <2.5 L/kg/minute would be appropriate in most situations.

Immediate Effects and Safety of High-Frequency Chest Wall Compression Compared to Airway Clearance Techniques in Non-Hospitalized Infants With Acute Viral Bronchiolitis.

BACKGROUND: No studies have investigated the use and safety of high-frequency chest wall compression (HFCWC) for non-hospitalized infants with acute viral bronchiolitis (AVB). The aim of the present study was to evaluate the immediate effects and safety of HFCWC as compared to airway clearance techniques in children with AVB. METHODS: In this randomized clinical trial in non-hospitalized infants (0-12 months old) with mild to moderate AVB, children were randomized into 2 groups: airway clearance techniques (20 min of prolonged slow expiration and provoked cough) or HFCWC (15 min). A single session was performed and children were evaluated at baseline and at 10 min and 20 min after treatments. Outcomes measures were the Wang severity score, [Formula: see text], sputum wet-weight, and the presence of adverse events. RESULTS: A total of 91 infant subjects, mean age 7.9 ± 2.6 months, were included. Significant (P = .004) between-group differences were found in the Wang score, which was 0.28 points lower in the airway clearance techniques group. There was a greater increase of infants classified as normal and a greater decrease of those classified as mild according to the Wang score when airway clearance techniques were used compared to the use of HFCWC (P = .009). The sputum wet-weight was lower in subjects treated with the airway clearance techniques (P < .001). Although [Formula: see text]improved in both groups, no differences were found between them. There was also no difference for adverse events, and the majority of children did not present any adverse events after 20 min. CONCLUSIONS: The use of HFCWC induced similar clinical effects as airway clearance techniques and was safe for non-hospitalized infants with AVB. Both techniques reduced respiratory symptoms and acutely improved [Formula: see text]. (ClinicalTrials.gov: NCT03835936.).

Identifying and managing bronchiolitis.

Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.

High flow nasal cannula as respiratory support in treating infant bronchiolitis: a systematic review.

Bronchiolitis is a common respiratory illness in early childhood, often leading to hospitalization and associated healthcare costs. Low flow 100% oxygen through nasal prongs is the standard therapy for infants with bronchiolitis and hypoxemia. Nasal continuous positive airway pressure (nCPAP) or invasive ventilation is used in case of progressive respiratory failure. High flow heated and humidified oxygen therapy with delivery of an air-oxygen mixture up to 2 L/min/kg body weight via nasal prongs (referred to as high flow nasal cannula or HFNC) is a newer method for respiratory support. Initial data from retrospective studies were promising but should be interpreted with caution. A limited number of prospective randomized controlled trials (RCT) have now compared HFNC with either standard oxygen therapy (SOT) or nCPAP. In this review, we critically summarize the data from these RCTs with the aim to provide advice on how to position HFNC in clinical practice.Conclusion: HFNC is a safe mode of respiratory support that can be positioned between SOT and nCPAP as rescue therapy for children not adequately supported by SOT. It does not seem to shorten the duration of oxygen need nor the duration of hospital admission.What is Known:• HFNC is being used increasingly in the context of infant bronchiolitis. However, evidence on efficacy and safety are limited. Different published studies involve different disease severities and different pediatric settings.What is New:• In this review, we summarize data only from prospective RCTs with the aim to provide guidance on how to use HFNC.